Wegener's granulomatosis: prospective clinical and therapeutic experience with 85 patients for 21 years

Lacrimal gland enlargement as one of the ocular manifestations of Wegener's granulomatosis

Wegener's granulomatosis is characterized by chronic, focal, necrotizing and granulomatous vasculitis. The localized form involves mainly the upper or lower respiratory tracts, or both. In the commoner generalized form, the kidneys are also affected. Literature findings suggest that ocular manifestations are a predominating sign in about 30% of cases. Ocular findings may include conjunctivitis, keratitis and sclerouveitis, pseudotumor of the orbit or proptosis. We report on a patient who showed bilateral episcleritis, keratitis, nasolacrimal duct obstruction and enlargement of the lacrimal gland. The latter finding was confirmed by CT scan.

Wegener's granulomatosis: observations on treatment with antimicrobial agents

Twelve patients with Wegener's granulomatosis were treated with antimicrobial agents, chiefly trimethoprim-sulfamethoxazole. The clinical course improved in 11 of the 12 patients who received this treatment. The success of antimicrobial treatment suggests the possibility of a microbial infection as the inciting cause of Wegener's granulomatosis in some patients. Alternatively, these agents--in particular, trimethoprim-sulfamethoxazole--may possess immunosuppressant activity.

Wegener's granulomatosis with destructive ocular manifestations

A 27-year-old man developed bilateral destructive ocular manifestations of generalized Wegener's granulomatosis. Before the appearance of necrotic granuloma, which replaced almost all the original ocular components, the patient had suffered from severe headache and restricted ocular motility for five years. A general remission was achieved with azathioprine and prednisolone treatment although the patient is blind because of destruction of the globes.

Cyclophosphamide (Cytoxan). A review on relevant pharmacology and clinical uses

Cyclophosphamide (Cytoxan; Cy) is an alkylating agent with cytotoxic and immunosuppressive activities. The parent compound is inactive in vitro and exerts its biologic activity through metabolites, mainly phosphoramide mustard generated by hepatic microsomal enzymes. The exact mode of cytotoxic and immunosuppressive action of Cy at cellular level is not completely understood. Myelosuppression, hemorrhagic cystitis, alopecia, and gonadal damage are the main toxic effects. Available data suggest that Cy has carcinogenic potential in humans. Cy is widely used for cancer chemotherapy. As an immunosuppressive agent, it is successfully used in certain nonmalignant diseases in which autoimmune phenomena are established or suspected in the pathogenesis of the disease. It is the drug of choice in Wegener's granulomatosis. Extensive efforts are being made to synthesize Cy analogues with greater selective cytotoxic and immunosuppressive activity. Ifosfamide, a Cy analogue, appears to possess similar cytotoxic activity with less myelosuppression. Further research will help in synthesizing a Cy analogue with specific pharmacologic activity and reduced or absent harmful effects.

Severe intestinal involvement in Wegener's granulomatosis

A case of Wegener's granulomatosis is described, in which the presentation was blood stained mucus diarrhoea. Severe ileal, caecal, and rectal involvement improved rapidly after treatment with cyclophosphamide, azathioprine, and prednisolone. Although intestinal disease is an uncommon feature of Wegener's granulomatosis, both in our own experience (four of 45 cases) and in the literature, this diagnosis should be considered in view of the response to appropriate therapy.

Renal biopsy findings in Wegener's granulomatosis: segmental necrotizing glomerulonephritis with glomerular thrombosis

The clinicopathologic features of 14 patients with documented Wegener's granulomatosis (WG), with a detailed analysis of renal biopsy findings, are presented. The characteristic renal lesion found in all initial and in three of eight follow-up biopsies was segmental necrotizing glomerulonephritis (SNGN). The SNGN was generally focal and involved more than 60 per cent of the glomeruli in only two specimens. Light microscopic evidence of glomerular thrombosis, with or without necrosis, was found in 60 per cent of the biopsies. By immunofluorescence fibrin was demonstrated in 54 per cent of the biopsy specimens with "acute" SNGN, while 36 per cent of the specimens lacked both IgG and C3. Electron microscopy showed fibrin(oid) deposition with variable platelet activation associated with mesangionecrosis (two specimens) and peripheral glomerular basement membrane fragmentation/dissolution (three specimens). Rare discrete intramembranous (four specimens) and mesangial/subendothelial (one specimen) dense deposits were identified, but these deposits were associated with necrosis in only two biopsies. These findings fail to demonstrate an immune complex pathogenesis for the SNGN and suggest that glomerular thrombosis and necrosis are the primary findings in WG.

Diffuse histiocytic lymphoma in a patient treated with cyclophosphamide for Wegener's granulomatosis

Diffuse histiocytic lymphoma developed in a 48-year-old man with Wegener's granulomatosis after nine years of therapy with cyclophosphamide. He died despite aggressive surgical and medical therapy for the lymphoma. This may be the first report of diffuse histiocytic lymphoma following treatment of Wegener's granulomatosis with cyclophosphamide. Recommendations for the approach towards extended therapy of smoldering Wegener's granulomatosis are discussed.

Acute glomerulonephritis. A clinical overview

Acute glomerulonephritis is a syndrome characterized by the abrupt onset of hematuria often accompanied by proteinuria, hypertension, edema, and renal dysfunction. Acute glomerulonephritis can be subdivided into primary glomerular disease, postinfectious glomerulonephritis, and glomerulonephritis associated with systemic disease. With few exceptions, the underlying mechanism of acute glomerulonephritis is an immunologic one. To differentiate clinically the specific etiology of the glomerulonephritis, attention must be focused on the presence of signs or symptoms of systemic disease, changes in the environment of the patient, family history of renal disease, and recent history of infectious disease.

The pathology of idiopathic midline destructive disease (IMDD) in the eyelid

Subcutaneous eyelid and brow nodules were noted in a 25-year-old man who, at the age of 14 years, had developed the central facial and upper airway necrosis characteristic of idiopathic midline destructive disease (IMDD). One large nodule was located near the lateral canthus rather than a midline position. Insofar as we know, this report would constitute the first evidence of IMDD in the eyelids and brow in the absence of orbital disease.

Therapy for immunologic disease. New ways of using old drugs

Treatment of immunologically mediated diseases has been hampered by the lack of therapeutic agents capable of selectively altering distinct areas of the immune network. Unfortunately, most immunomodulating drugs with such capability are not selective in their suppressive effects, often causing untoward reactions such as infection. In an attempt to obviate these effects, new schemes of administering these agents so as to minimize adverse side effects and maximize benefits have been developed. Such regimens utilizing corticosteroids and certain cytotoxic drugs are proving effective. Progress will probably be limited to the devising of new protocols for existing pharmacologic agents until newer drugs are developed that can more precisely modify specific phases of the exaggerated immune reactivity characteristic of immunologically mediated diseases.

SSA (Ro)-antibodies in Wegener's granulomatosis

In 4 consecutive cases of Wegener's granulomatosis with glomerulonephritis, antibodies against the extractable nuclear antigen SSA (Ro) could be demonstrated with counterimmunoelectrophoresis. Antibodies were demonstrable on admission and paralleled disease activity while patients were under therapy. This potential serological marker may be of value for diagnosis and follow-up of patients with Wegener's granulomatosis.